Medical Care Practices Research Articles

Strategies for working with elderly clients: a qualitative analysis of elderly client/nurse practitioner communication.

To describe communication between nurse practitioners (NPs) and elderly clients. A qualitative study using a focus group composed of 6 NPs and in-depth interviews of an additional 6 NPs who provide care to elderly clients in a variety of settings. The NPs described a framework of critical thinking, termed hypervigilance, which they enter before and during an interaction with an elderly client. Specific communication strategies were identified that increased the likelihood of compliance with or adherence to treatment regimens for elderly clients. Hypervigilance is descriptive of actively working to merge nursing practice with traditional medical primary care practice. This finding raises the issue of the difference in practice between physicians and NPs in regards to communication with clients.

Fever phobia revisited: have parental misconceptions about fever changed in 20 years?

Fever is one of the most common reasons that parents seek medical attention for their children. Parental concerns arise in part because of the belief that fever is a disease rather than a symptom or sign of illness. Twenty years ago, Barton Schmitt, MD, found that parents had numerous misconceptions about fever. These unrealistic concerns were termed "fever phobia." More recent concerns for occult bacteremia in febrile children have led to more aggressive laboratory testing and treatment. Our objectives for this study were to explore current parental attitudes toward fever, to compare these attitudes with those described by Schmitt in 1980, and to determine whether recent, more aggressive laboratory testing and presumptive treatment for occult bacteremia is associated with increased parental concern regarding fever. Between June and September 1999, a single research assistant administered a cross-sectional 29-item questionnaire to caregivers whose children were enrolled in 2 urban hospital-based pediatric clinics in Baltimore, Maryland. The questionnaire was administered before either health maintenance or acute care visits at both sites. Portions of the questionnaire were modeled after Schmitt's and elicited information about definition of fever, concerns about fever, and fever management. Additional information included home fever reduction techniques, frequency of temperature monitoring, and parental recall of past laboratory workup and treatment that these children had received during health care visits for fever. A total of 340 caregivers were interviewed. Fifty-six percent of caregivers were very worried about the potential harm of fever in their children, 44% considered a temperature of 38.9 degrees C (102 degrees F) to be a "high" fever, and 7% thought that a temperature could rise to >/=43.4 degrees C (>/=110 degrees F) if left untreated. Ninety-one percent of caregivers believed that a fever could cause harmful effects; 21% listed brain damage, and 14% listed death. Strikingly, 52% of caregivers said that they would check their child's temperature </=1 hour when their child had a fever, 25% gave antipyretics for temperatures <37.8 degrees C (<100 degrees F), and 85% would awaken their child to give antipyretics. Fourteen percent of caregivers gave acetaminophen, and 44% gave ibuprofen at too frequent dosing intervals. Of the 73% of caregivers who said that they sponged their child to treat a fever, 24% sponged at temperatures </=37.8 degrees C (</=100 degrees F); 18% used alcohol. Forty-six percent of caregivers listed doctors as their primary resource for information about fever. Caregivers who stated that they were very worried about fever were more likely in the past to have had a child who was evaluated for a fever, to have had blood work performed on their child during a febrile illness, and to have perceived their doctors to be very worried about fever. Compared with 20 years ago, more caregivers listed seizure as a potential harm of fever, woke their children and checked temperatures more often during febrile illnesses, and gave antipyretics or initiated sponging more frequently for possible normal temperatures. Fever phobia persists. Pediatric health care providers have a unique opportunity to make an impact on parental understanding of fever and its role in illness. Future studies are needed to evaluate educational interventions and to identify the types of medical care practices that foster fever phobia.fever, fever phobia, child, children, antipyretics, sponging, health care practices.

Towards Better Reproductive Health in Eastern Europe. Concern, Commitment and Change by G. s&gt; Lindmark M. Horga A. Campana , J. Kasonde (review)

386 SEER, 79, 2, 200I This is definitelynot a book to be recommended to mainstreameconomists, and not even to 'transitologists'keen on economic developmentsonly. This is a book to take on an air flight or better a railway trip and to enjoy withoutprejudice. ISMEA(Institute ofApplied Mathematics andEconomics) M. LAVIGNE Paris Lindmark,G.; Horga, M.; Campana, A. and Kasonde,J. (eds). Towards Better Reproductive HealthinEastern Europe. Concern, Commitment andChange. WHO Scientific Working Group on Reproductive Health Research. Central European University Press, Budapest, and WHO, Geneva, I999. xiv + 150 pp. Tables. Figures.Bibliographies.?9.99 (paperback). THE identificationof a significantgap in healthstatusand healthcare between the post-Communist countries and those of advanced Western economies predatedthefallof Communism,but the shocksand dislocationsof 'transition' saw the gap widening. Graveconcernshave been expressedfor manyyearsat the numerous examples of deteriorating indices of health, including basic indicators such as life expectancy and infant mortality. Premature male mortalityattractedparticularattention.Onlyveryrecentlydidtheseindicators improve in certaincountriesof CentralEurope;but furtherdeteriorationwas evident throughoutmost of the formerSoviet Union. A study of reproductive health ought therefore to be very welcome, not least because the health gap is paralleledby a researchgap in this area. Even the thoughtful,wide-rangingrecent studyby William Cockerham(Healthand SocialChange inRussiaandEastern Europe, London, i999) largelyignoreswomen in generaland reproductivehealthin particular.Unfortunately,thiscollection of chaptersby the WHO ScientificWorkingGroup on Reproductive Health Research is tedious and repetitive. Its data are drawn mainly from the first half of the I99os, so that it does not even have the merit of providing an upto -date overview. Some of the data do not appear consonant with those available elsewhere, such as the surprising figures for life expectancy in Turkmenistan of 62 years for women and 69 for men (Honjanen and Benagiano, p. 2). It is not that the materialsprovided offeran erroneouspicture. Indeed, the problems identified will be all too familiar to the 'policymakers and programmemanagers'who are the targetaudience. These includehigh levels of maternal and infant mortality, low use of contraception, high abortion rates,yet risingteenage pregnancies, and an epidemic of sexuallytransmitted disease,probablylinkedto infertility.The reasonsadduced for suchproblems are also familiar ones. Some are a result of health care organization and medical practice. They include the lack of emphasis on primaryprevention, poor standardsof medical training (forobstetricsand gynaecology, if not for dermatology and venerealogy), authoritarianattitudes to and little involvement of patients with their care, the persistence of traditionalpractices and obsolete treatmentregimens.Othersarea resultoflackof resources,especially with regardto familyplanning servicesand contraception,with abortion still REVIEWS 387 the main means of fertilitycontrol. This is particularlyimportant given the strong association between lack of contraception and maternal, infant and perinatalmortality(Kovacs, p. 9 I). Moreover there is an absence of integration of health and education, in particularsex education, and a similarlackof coordinationprevailswith regardto linksbetween health care and police and social services. These points, and general considerations of economic dislocation , are not part of a sustainedanalysisor a unified theme developed in particularchapters. Despite the recognition of variation between and within countries,and numerouschartsand tablesto illustratethe former,there is no sustained comparative analysis of the reasons for such differences. The political, social and economic context of post-Communist transformation appearsonly at the margins.The particularissuessurroundingredefinitionof gender roles and the specific impact of this profound change on women are addressednot at all. Moreover, the solutions offeredare either obvious or wildly unrealistic.In the first category are pleas for the establishment of efficient and sensitive family planning services and free contraception. The second includes recommendationsfor a qualityassuranceprocess,includingsetting'standards for quality of care in structure, process, and outcomes' (Lindmark,p. 30). Scholarsand otherinterestedpersonswillfindlittleto stimulatetheirinterest. Department ofGovernment FRANCESMILLARD University ofEssex Lavenex, Sandra. SafeThirdCountries. Extending theEU Asylum andImmigration Policiesto Central andEastern Europe. Central European University Press, Budapestand New York,i999. xii + I89 pp. Notes. Bibliography.Index. ? 13.95 (paperback). THE aim of this book is to demonstrate that the European Union's (EU's) currentasylumregimewhich isgearedtowardscombatingillegalimmigration, weakensthe principles,normsand rulesof internationalrefugeeprotectionby impeding the entry of asylum seekers and that it establishes a system of negative redistributionfor handling asylumclaimsthat impactsupon Central and EasternEuropean Countries (CEECs).Additionally,the fieldsof asylum and immigration, although not originallypart of the EU's agenda, now play an increasinglyimportantrole in the pre-accessionstrategydeployed vis-a-vis CEECs, and this, the author argues, may place significantobstacles to swift...

Provision of Methadone Treatment in Primary Care Medical Practices: Review of the Scottish Experience and Implications for US Policy

Provision of Methadone Treatment in Primary Care Medical Practices: Review of the Scottish Experience and Implications for US Policy

Design of the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial

The objectives of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial are to determine in screenees ages 55–74 at entry whether screening with flexible sigmoidoscopy (60-cm sigmoidoscope) can reduce mortality from colorectal cancer, whether screening with chest X-ray can reduce mortality from lung cancer, whether screenng men with digital rectal examination (DRE) plus serum prostate-specific antigen (PSA) can reduce mortality from prostate cancer, and whether screening women with CA125 and transvaginal ultrasound (TVU) can reduce mortality from ovarian cancer. Secondary objectives are to assess screening variables other than mortality for each of the interventions including sensitivity, specificity, and positive predictive value; to assess incidence, stage, and survival of cancer cases; and to investigate biologic and/or prognostic characterizations of tumor tissue and biochemical producs as intermediate endpoints. The design is a multicenter, two-armed, randomized trial with 37,000 females and 37,000 males in each of the two arms. In the intervention arm, the PSA and CA125 tests are performed at entry, then annually for 5 years. The DRE, TVU, and chest X-ray exams are performed at entry and then annually for 3 years. Sigmoidoscopy is performed at entry and then at the 5-year point. Participants in the control arm follow their usual medical care practices. Participants will be followed for at least 13 years from randomization to ascertain all cancers of the prostate, lung, colorectum, and ovary, as well as deaths from all causes. A pilot phase was undertaken to assess the randomization, screening, and data collection procedures of the trial and to estimate design parameters such as compliance and contamination levels. This paper describes eligibility, consent, and other design features of the trial, randomization and screening procedures, and an outline of the follow-up procedures. Sample-size calculations are reported, and a data analysis plan is presented.

Seven legal barriers to end-of-life care: myths, realities, and grains of truth.

The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care. The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM. A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience. The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process. Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501.

New transient ischemic attack and stroke: outpatient management by primary care physicians.

Patients with transient ischemic attack (TIA) or stroke frequently first contact their primary care physician rather than seeking care at a hospital emergency department. The purpose of the present study was to identify a group of patients seen by primary care physicians in an office setting for a first-ever TIA or stroke and characterize their evaluation and management. Practice audit based on retrospective, structured medical record abstraction from 27 primary care medical practices in 2 geographically separate communities in the eastern United States. Ninety-five patients with a first-ever TIA and 81 with stroke were identified. Seventy-nine percent of those with TIA vs 88% with stroke were evaluated on the day their symptoms occurred (P =.12). Only 6% were admitted to a hospital for evaluation and treatment on the day of the index visit (2% TIA; 10% stroke; P =.03); only an additional 3% were admitted during the subsequent 30 days. Specialists were consulted for 45% of patients. A brain imaging study (computed tomography or magnetic resonance imaging) was ordered on the day of the index visit in 30% (23% TIA, 37% stroke; P =.04), regardless of whether the patient was referred to a specialist. Carotid ultrasound studies were obtained in 28% (40% TIA, 14% stroke; P<.001), electrocardiograms in 19% (18% TIA, 21% stroke; P =.60), and echocardiograms in 16% (19% TIA, 14% stroke; P =.34). Fewer than half of patients with a prior history of atrial fibrillation (n = 24) underwent anticoagulation when evaluated at the index visit. Thirty-two percent of patients (31% TIA, 33% stroke; P =.70) were not hospitalized and had no evaluations performed during the first month after presenting to a primary care physician with a first TIA or stroke. Of these patients, 59% had a change in antiplatelet therapy on the day of the index visit. Further primary care physician education regarding the importance of promptly and fully evaluating patients with TIA or stroke may be warranted, and barriers to implementation of established secondary stroke prevention strategies need to be carefully explored. Arch Intern Med. 2000;160:2941-2946

The role of epidemiology in the committee on the costs of medical care

Among the most important 20th century documents of American public health is the 1932 report of the Committee on the Costs of Medical Care (CCMC). In May 1927, leaders of medicine, public health, and the social sciences, met at the annual meeting of the AMA, to consider that, despite advances in medical sciences, a vast amount of preventable disease and unnecessary death existed. A committee of 50 men and women, the CCMC, was formed to investigate. Of the six public health members, three were epidemiologists. A spectrum of governmental and private organizations supported the CCMC and eight foundations provided funding. A staff of 51 conducted 26 studies, many epidemiological, to support its five categorical recommendations. Briefly these were: 1) Medical services, preventive and therapeutic, should be provided by interdisciplinary groups; 2) Basic public health services should be available to all without cost; 3) The costs of medical care should be placed on a group basis (insurance, taxation, or a combination thereof); 4) Study, evaluation, and coordination of medical and public health services should be important functions for local and state governments; and 5) Professional education for a wide variety of medical and public health personnel should be greatly expanded with emphasis on prevention and social considerations.Perhaps the most interesting of the CCMC's epidemiological studies was, “The Incidence of Illness and the Receipt and Costs of Medical Care Among Representative Families: Experiences in Twelve Consecutive Months During 1928–1931.” This study included 8,639 families comprising 38,668 persons and described the then current status of medical care and public health practice in the U.S.A.The final report of the CCMC contained minority reports ranging from claims that the recommendations were too radical to assertions that they didn't go far enough! Nevertheless, they have been the focus for medical and public health concern and controversy for almost three-quarters of a century. Their roots in epidemiology should not be forgotten!

META-ANALYSIS IN HEMATOLOGY AND ONCOLOGY

In 1992, a review article about meta-analysis identified only 15 meta-analyses of randomized, controlled trials of cancer therapy. Since then, the total number of meta-analyses in this field has increased almost sixfold. More importantly, the number of randomized, controlled trials in this discipline has also grown tremendously. The expansion in the literature will provide a fertile ground for future meta-analyses. The quality of the recent publications has also improved. An ongoing world-wide effort, the Cochrane Collaboration, is systematically assembling and synthesizing several hundred thousand randomized, controlled trials to improve the delivery of health care. Meta-analysis has many important advantages. It allows the viewing of the complete picture of the evidence. The advent of meta-analysis has sensitized researchers to issues of quality and has improved methodology in clinical research. Detection and explanation of bias and heterogeneity are prime objectives of meta-analysis in clinical research. An array of methods has been developed that allows a better understanding of bias and heterogeneity, beyond simple averaging of results from diverse studies. Meta-analyses of individual patient data, in particular, may promote the development of international collaborations. Several examples of their application are already available in oncology. Meta-analysis may point out deficiencies in the study design of past and current studies, suggest the need for new studies, and inform researchers about the size and design of these studies. In the end, meta-analysis helps to integrate evidence and make recommendations for medical care and medical practice.

How much do persons with Alzheimer's disease cost Medicare?

Medicare claims are increasingly being used to identify persons with chronic diseases such as Alzheimer's disease (AD) for the purpose of determining the cost to Medicare of caring for such persons. Past work has been limited by the use of only 1 or 2 years of claims data to identify cases, leading to worries that this might lead to an undercount of prevalent cases and bias cost findings. To analyze the average total cost to the Medicare program in 1994 of persons with a claims-based diagnosis of AD, using a 12-year period of claims history to identify prevalent cases, and to investigate the effect on cost of time since diagnosis. A cross-sectional design with a 12-year retrospective period to identify persons with AD. Medical care practices, hospitals, and other providers of services to Medicare beneficiaries in the US in 1994. Respondents to the screener (n = 10,858) and community (5429) and institutional (n = 1341) questionnaire of the 1994 National Long Term Care Survey, with and without a claims-based diagnosis of AD. Average total cost to Medicare in 1994, measured as the actual amount Medicare paid for inpatient, outpatient, home health, skilled nursing facility, hospice, and Part B services, including payments to physicians, and other items such as durable medical equipment. We also measured disability in a variety of ways, including cognition, activity limitations, and residence in a nursing home. The average total cost to Medicare of persons with a claims-based diagnosis of AD was $6021 versus $2310 (P < .001) for persons without a diagnosis. When adjusting for patient characteristics, the ratio of cost between persons with AD and those without was reduced to about 1.6 to 1. Time since diagnosis was an important predictor of average total cost in 1994, with each additional year since diagnosis resulting in a $248 (P = .04) decrease in total cost (about 10% of the total sample mean cost of $2426). There was mixed evidence that persons with a diagnosis of AD incurred less cost than otherwise similarly disabled Medicare beneficiaries. Time since diagnosis with AD is an important predictor of cost and one that should be explicitly included in any rate-setting formula. Expanding the period used to identify cases resulted in an increase in the unadjusted ratio of cost of a Medicare beneficiary with AD relative to one without primarily because our control group costs are lower compared with those of past work.

Health care and health status and outcomes for patients with type 2 diabetes.

To evaluate access and utilization of medical care, and health status and outcomes that would be influenced by recent medical care, in a representative sample of patients with type 2 diabetes. A national sample of 733 adults with type 2 diabetes was studied from 1991 to 1994 in the Third National Health and Nutrition Examination Survey. Structured questionnaires and clinical and laboratory assessments were used to determine the frequencies of physician visits, health insurance coverage, screening for diabetes complications, treatment for hyperglycemia, hypertension, and dyslipidemia; and the proportion of patients who met treatment goals and established criteria for health outcome measures including hyperglycemia, albuminuria, obesity, hypertension, and dyslipidemia. Almost all patients had 1 source of primary care (95%), 2 or more physician visits during the past year (88%), and health insurance coverage (91%). Most (76%) were treated with insulin or oral agents for their diabetes, and 45% of those patients taking insulin monitored their blood glucose at least once per day The patients were frequently screened for retinopathy (52%), hypertension (88%), and dyslipidemia (84%). Of those patients with hypertension, 83% were diagnosed and treated with antihypertensive agents and only 17% were undiagnosed or untreated; most of the patients known to have dyslipidemia were treated with medication or diet (89%). Health status and outcomes were less than optimal: 58% had HbA1c >7.0, 45% had BMI >30, 28% had microalbuminuria, and 8% had clinical proteinuria. Of those patients known to have hypertension and dyslipidemia, 60% were not controlled to accepted levels. In addition, 22% of patients smoked cigarettes, 26% had to be hospitalized during the previous year, and 42% assessed their health status as fair or poor. Rates of health care access and utilization, screening for diabetes complications, and treatment of hyperglycemia, hypertension, and dyslipidemia in type 2 diabetes are high; however, health status and outcomes are unsatisfactory. There are likely to be multiple reasons for this discordance, including intractability of diabetes to current therapies, patient self-care practices, physician medical care practices, and characteristics of U.S. health care systems.

Provision of methadone treatment in primary care medical practices: review of the Scottish experience and implications for US policy.

Under new proposed regulations, US physicians outside of traditional methadone clinics could prescribe methadone to patients with opioid dependence. No large-scale evaluations of US programs in which methadone maintenance is provided by primary care physicians are available, but primary care physicians in Scotland have participated in such programs on a large scale. To review the history, operation, and outcome data on the efficacy and safety of 2 Scottish primary care-based opioid agonist treatment programs to derive lessons for the US context. Naturalistic study of programs in Edinburgh and Glasgow, Scotland, with data obtained through site visits and interviews conducted in 1996 and 1998, as well as from published reports and retrospective analysis of electronic databases. Proportions of injection drug users who were enrolled in the methadone maintenance programs, average methadone doses in the programs, and methadone-related deaths. A total of 60% to 80% of injection drug users in Edinburgh and 41% to 73% of those in Glasgow were enrolled in methadone maintenance in 1998-1999. Dose levels are consistent with US recommendations (for Edinburgh in 1998, 61 mg; for Glasgow in 1994-1996, 54 mg). The Glasgow program required supervised consumption of methadone in community pharmacies for the first year and experienced significantly fewer methadone-related deaths than Edinburgh in 1997 (17 vs 30 deaths; P<.0001). Programs in both Edinburgh and Glasgow provided support to primary care physicians and achieved levels of general practitioner participation of 59% (1998) and 30% (1999), respectively. The Scottish experience indicates that prescription of methadone in office-based settings can expand access to an important treatment modality. Primary care physicians safely prescribed methadone for maintenance treatment when provided with adequate support. Diversion of methadone was minimized by requiring supervised consumption in community pharmacies.

Caring and Curing: Health and Medicine in the Western Religious Traditions

Most religious traditions have a rich, if largely forgotten, heritage of involvement in medical issues of life, death, and health. Religious values influence our behavior and attitudes toward sickness, sexuality, and lifestyle, to say nothing of more controversial subjects such as abortion and euthanasia. The essays in this important book illuminate the history of health and medicine within the Judeo-Christian tradition. Bringing together 20 original articles by expert scholars in the fields of the history of religion and the history of medicine, Caring and Curing provides a fascinating and enlightening overview of how religious values have come to affect the practice of medicine and medical care.

Stroke-related knowledge among patients with access to medical care in the stroke belt

North Carolina lies in the country's Stroke Belt, which is a region where cerebrovascular disease is a major public health problem. We performed an open survey of patients residing in a Stroke Belt community who had access to medical care to determine their level of knowledge about stroke risk factors, symptoms, and emergency procedures. Between June and December 1997, a random sample of patients, over age 55, at 13 primary care medical practices in central North Carolina were asked to complete an open questionnaire. Responses were obtained from 202 patients (78% Caucasian, 18% African American, 4% other or unstated). Overall, 80% of those who responded believed that stroke could be, prevented, and 95% felt that stroke could be treated. Although only 12% could not correctly name any stroke risk factors, 53% could not list any of the symptoms of a transient ischemic attack (TIA), and 25% could not provide any stroke, symptoms. Multiple regression analyses showed that knowledge of stroke risk factors was independently related to both age and race (multiple r=.29, P<.0004; P<.01, for age and P<.01 for race) and that knowledge of stroke symptoms was independently related to age with a trend towards an effect of race (multiple r=.18, P<.04; P=.05 for age and P=.08 for race). This study shows that even for patients with access to medical care residing in a portion of the country with a particularly high incidence of cerebrovascular disease, knowledge of stroke risk factors, TIA symptoms, and stroke symptoms remains relatively poor. Those at higher epidemiological risk for cerebrovascular disease were relatively less knowledgeable. Based on these data, the need for local public education, particularly within Stroke Belt communities, requires further emphasis.

General practice and the care of children with HIV infection: 6 month prospective interview study

Objectives: To describe the use of primary care services by children infected with HIV and to explore the attitudes of their parents to the role of general practitioners in their...

The costs and consequences of management fads and politically driven regulatory oversight.

The period from the mid-1980s to the present has seen a virtual revolution in how blood collection, testing, and transfusion are carried out. Most of the changes that have occurred represent changes in organization, underlying paradigms of transfusion safety, and approaches to solutions to perceived problems, rather than technical or scientific advances. These changes were instituted with little or no data to support their safety and efficacy, much less their cost-effectiveness. Using data on changes in fees charged by regional blood centers during this period, an estimate was generated of the costs attending the purely administrative and organizational changes in the field of transfusion medicine. The additional expenditures, excluding inflation, are in the range of $226 million per year. This figure does not include changes in infectious disease testing on donated blood, the substantive scientific advance during this period. In addition to the questions of safety and efficacy, which are traditionally considered prior to clinical or procedural changes of this magnitude, the question remains whether these expenditures are a reasonable trade-off of cost versus benefit. Similar applications of federal regulatory standards intended for manufacturing (eg, good manufacturing practices) and industrial management theory (eg, total quality management) are now being implemented or proposed for hospitals, health care delivery systems, and individual physician's practices. Thus, the case of transfusion medicine may provide some cautionary lessons for future proposed changes in health care delivery and medical practices.

Effectiveness of treatments for major depression in primary medical care practice: a post hoc analysis of outcomes for African American and white patients

Objective: To retrospectively determine whether race differentially influences treatment adherence and clinical outcomes among 68 African Americans and 92 whites treated for major depression in four urban, primary care settings. Method: Study participants were randomly assigned to standardized interpersonal psychotherapy or pharmacotherapy with nortriptyline, and were assessed at baseline, and successive time points up to 8 months for severity of depression, and mental and physical health-related functioning. Results: Intent-to-treat analyses revealed no treatment or race-specific differences in symptomatic recovery when both groups were provided standardized psychotherapy or pharmacotherapy. However, African Americans had poorer functional outcomes than whites. Conclusions: African American and white primary medical care patients are effectively treated with standardized psychotherapy and pharmacotherapy. Future research should assess the impact of cultural context on symptom presentation, psychosocial functioning, and treatment adherence and response.

Physician-based physical activity counseling for middle-aged and older adults: A randomized trial

Sedentary behavior among older adults increases risk for chronic diseases. Physicians in a primary care setting can play an important role in promoting physical activity adoption among their older patients. The Physically Active for Life (PAL) project was a randomized, controlled trial comparing the efficacy of brief physician-delivered physical activity counseling to usual care on self-reported physical activity levels. The physical activity counseling was based on the Transtheoretical Model of Change and social learning theory. Twenty-four community-based primary care medical practices were recruited into the study; 12 were randomized to the Intervention condition and 12 to the Control condition. Physicians in the Intervention practices received training in the delivery of brief physical activity counseling. Subjects in the Intervention practices (n=181) received brief activity counseling matched to their stage of motivational readiness for physical activity, a patient manual, a follow-up appointment with their physician to discuss activity counseling, and newsletter mailings. Subjects in the Control practices (n=174) received standard care. Measures of motivational readiness for physical activity and the Physical Activity Scale for the Elderly (PASE) were administered to subjects in both conditions at baseline, 6 weeks following their initial appointment, and at 8 months. Results showed that at the 6-week follow-up, subjects in the Intervention condition were more likely to be in more advanced stages of motivational readiness for physical activity than subjects in the Control condition. This effect was not maintained at the 8 month follow-up and the intervention did not produce significant changes in PASE scores. Results suggest that more intensive, sustained interventions may be necessary to promote the adoption of physical activity among sedentary, middle-aged, and older adults in primary care medical practices.

Health psychology: mapping biobehavioral contributions to health and illness.

Our evolving understanding of how psychosocial and behavioral factors affect health and disease processes has been marked by investigation of specific relationships and mechanisms underlying them. Stress and other emotional responses are components of complex interactions of genetic, physiological, behavioral, and environmental factors that affect the body's ability to remain or become healthy or to resist or overcome disease. Regulated by nervous, endocrine, and immune systems, and exerting powerful influence on other bodily systems and key health-relevant behaviors, stress and emotion appear to have important implications for the initiation or progression of cancer, HIV, cardiovascular disease, and other illnesses. Health-enhancing and health-impairing behaviors, including diet, exercise, tobacco use, and protection from the sun, can compromise or benefit health and are directed by a number of influences as well. Finally, health behaviors related to being ill or trying to avoid disease or its severest consequences are important. Seeking care and adhering to medical regimens and recommendations for disease surveillance allow for earlier identification of health threats and more effective treatment. Evidence that biobehavioral factors are linked to health in integrated, complex ways continues to mount, and knowledge of these influences has implications for medical outcomes and health care practice.

鼻処置の有用性について １． 実地診療からみた鼻処置の評価

鼻処置の有用性について １． 実地診療からみた鼻処置の評価